=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972142719
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CATHEDRAL MEDICAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2019
-----------------------------------------------------
Last Update Date | 12/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2226 E CESAR E CHAVEZ AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90033-1825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-266-4445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 57629
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90057-0629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | VIKRAM S KOTHANDARAMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 213-840-4757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------